The nurse assists the client to ambulate for the first time, and documents the distance, pace, and support required. What item is also appropriate for the nurse to include in the documentation for this client?
1. Activity tolerance
2. Client's sense of security
3. Use of a gait belt
4. Where the client walked
Correct Answer: 1
In addition to the information supplied, the nurse should document how the client tolerated the activity, including vital signs, complaints of pain or discomfort, and strength. Client's sense of security, use of a gait belt, and where the client walked have already been documented.
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